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Environmental Health Department <br /> S A N�J O A Q U I N <br /> Lsitj'Y -----COUNTY --- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. if your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. <br /> 't..To b GOm feted b Y.APPLIGANT - <br /> 1 <br /> Business Name Lic.Plate# <br /> Owner/Operator Name 1r <br /> Bus4inesMai ng Address 1- r <br /> City State� S�Zip Bus. Ph Alt. Ph. <br /> hereby state that the above.information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San ,laaquin County Environmental Health Departfnent(EHD) requirements_ If the use of the <br /> commissary is discontinued,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. __11 <br /> Signature�yt.�l.,l'`lA n QY'1.12C�2. Date /Li. <br /> 2'. To be'coli'n• leted'� �GGMMiSSARY OWNERtOPERATQR ' <br /> Commissary Nam �1 __LWCaA <br /> Address r) o CA S n 1 6 Bus. Phone 0112, <br /> City L Zip ,'�Z �OwneriOperator(Pz V0, o [ V <br /> wChe k ail appropriate services provided: <br /> astewater disposal D--3/-'compartment sink CrIlectrical hook-ups <br /> olid waste disposal VeFood preparation Toilet and handwashing <br /> Com- of& Cold water for cleaning © St re refrigerated food !?Potable water <br /> Store dry food/supplies Overnight parking ehicle wash <br /> 1, , hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge,and meets the California Health&Safety Code requirements. if the food facility <br /> operator fails to ly with the conditions of this agreement, o if this agreement is modified or cancelled, the <br /> commissary o sh otify HD' ediately. <br /> Signature Date <br /> 3.-76.be colic- feted b9 A76.EN1l HHn"Widid :dUt§1& 6 San Jda uirr,:Go. <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> RENS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0136 1 w+nnv.sfgov.org/ehd <br />